New Shareholder Form (Authorization Department - Market Institutions Deputy)

This form should be filledby the realbeneficiary (individual) of the ownership of the authorized person.

PERSONALINFORMATION:

1.1 Full Name (English) as shown in the Passport:

First Name / Middle Name / Grandfather Name / Surname

1.2 Full Name (Arabic)

اسم العائلة / اسم الجد / اسم الأب / الاسم الأول

1.3 Gender:

Male Female

Date of birth:1.4

Day / Month / Year

Place of birth:1.5

Nationality 1.6

Another Nationality 1.7

National Identification Number1.8

Expiry Date1.9

Day / Month / Year

Passport Number:1.10

Passport Expiry Date1.11

Day / Month / Year

Contact Information:

2.1 Permanent Residential Address

Address (1)
Address (2)
Country
City
State/ Region
Zip Code
Phone Number
Cell Phone Number
Fax Number
Email address

Qualifications

3.1Please fill in the following table according to the qualifications of the real beneficiary

Qualification / Name of institution / Country / Year Awarded

Work Experience

4.1 Information about Current Employer

Employer Name
Employer Address
Employer Phone Number
Job Tittle
Start Date
Employer Website

4.2 Career Record for the RealBeneficiary

3 / 2 / 1
Employer Name
Type of Business
Job Title, including Roles & Responsibilities
From
(year/month)
To
(Month/Year) / From
(Month/Year)
To
(Month/Year) / From
(Month/Year)
To
(Month/Year) / Period of service
Reason for Leaving

4.3 Is the real beneficiary, employed bya company owned by the Government of the Kingdom of Saudi Arabia or a companycontrolled by the Government of any other country?

Yes No

If yes, please provide details:

4.4 Does the real beneficiary occupy a position in the Government or play prominent role locally or in a foreign country ?

Yes No

If yes, please provide details:

4.5 Does the real beneficiary work for undisclosed person (s)?

Yes No

If yes, please provide details:

Financial situation and memberships Board of Directors:

5.1Approximate total annual income ofthe beneficiary (SAR)?

50,000 - 500,000

5,000,000 – 500,001

10,000,000 – 5,000,001

More than 10,000,000

5.2 Approximate net wealth of the beneficiary (SAR)?

50,000 - 500,000

5,000,000 – 500,001

10,000,000 – 5,000,001

More than 10,000,000

5.3 Sources of wealthofthe beneficiary

5.4Sources of funding for the purchaseof the authorized person shares (directly or indirectly)

5.5 Doesthe real beneficiary have any direct/indirect ownershipin the authorized persons?

Yes No

If yes, please provide details:

Authorized Person / Share Value / Percentage / Direct or Indirect ownership

5.6Is the real beneficiary a board member of any company inside or outside the Kingdom?

Yes No

If yes, please provide details:

Disciplinary and Investigations Record:

6.1 Has thereal beneficiary ever been a party to any civil litigation in the past ten years involving damages in amount in excess of SR 200,000 or equivalent?

Yes No

6.2Is the real beneficiary currentlya party to any civil litigation?

Yes No

6.3Are there any judgments or court orders that he/she is currently subject to, or with which the real beneficiary has not complied?

Yes No

6.4 Has the real beneficiary ever been a party to a scheme of arrangement; or entered into any form of compromise with his/her creditors in the past ten years involving an amount in excess of SR 200,000 or equivalent?

Yes No

6.5Has the real beneficiary ever been bankrupt, or served with a bankruptcy petition?

Yes No

6.6 Has the real beneficiary ever been a partner of a firm which was dissolved without the consent of all the partners?

Yes No

6.7 Hasthereal businessof the beneficiary ever been managed by someone else with either with his/her consent or not?

Yes No

Provide details if the answer is yes to any of the questions from 6.1 to 6.7:

6.8 Has the real beneficiary, or a company or firm of which the beneficiary is or was a partner, substantial shareholder, CEO or administrative officer ever been:

6.8.1Refused or restricted from the right to carry on any trade, business or profession for which a specific license, registration or other authorisation is required by rules and regulations in the Kingdomor any other foreign country?

Yes No

6.8.2 Censured, disciplined or disqualified by any professional or regulatory body (including a stock or futures exchange) in relation to any trade, business or profession?

Yes No

6.8.3 The subject of an investigation relating to him/her (or his/her company’s or firm’s) business activities conducted by a regulatory or criminal investigatory body (i.e. police, securities regulator, stock or futures exchange, or other regulatory body)?

Yes No

6.8.4 Judged by a court to be civilly liable for fraud, dishonesty or malfeasance?

Yes No

6.8.5 The subject of any disciplinary actions or proceedings that are currently pending?

Yes No

6.9 In the past ten years, has the Capital Markets Authority (CMA) or any other governmental authority in the Kingdom of Saudi Arabia or elsewhere ever:

6.9.1Found that the directly or indirect real beneficiary has made a false statement or omission?

Yes No

If yes, please provide details:

6.9.2 Found the direct or indirect real beneficiary has been involved in a violation of its rules or regulations?

Yes No

If yes, please provide details:

6.9.3Found the direct or indirect real beneficiary has been a cause of an investment-related business having its authorisation to do securities business refused, suspended, revoked, or restricted?

Yes No

If yes, please provide details:

6.9.4Entered a judgment or order against the direct / indirect real beneficiary in connection with securities business or any related activity?

Yes No

If yes, please provide details:

6.9.5 Imposed a civil money penalty on the real beneficiary?

Yes No

If yes, please provide details:

6.9.6 Entered a judgment or ordered the real beneficiary to cease and desist from any activity?

Yes No

If yes, please provide details:

6.10Currently, is the real beneficiary subject of any civil or criminal proceeding that could result in a “yes” answer to any part of Items 6.9?

Yes No

If yes, please provide details:

Declaration of the Real beneficiary:

I hereby certify and represent that the information in this Application (including all Supporting Documents) is complete, true and correct.

I confirm that I have reviewed the Capital Market Law ,its Implementing Regulations and AML/CTF regulation, and am aware of the offences contained therein relating to the making of incorrect or falsestatements.

I undertake that if any information in this Application changes before this Application is approved, I shallnotify the Authority in writing immediately – without any delay - of the changes.

I consent to the authority using or disclosing any information I have provided in this Application, or may provide in the future, for the purpose of carrying out its responsibilities

Real Beneficiary Name

Date //

Beneficiary Signature

ComplianceManager/ Officer Name Signature and Official Seal

Date //